Respiratory Examination

Respiratory examination  and questions for medical student exams, finals, OSCEs and MRCP PACES

 

Intro (WIIPPPPE)

• Wash your hands
• Introduce yourself
• Identity of patient – confirm
• Permission (consent and explain examination)
• Pain?
• Position at 45°
• Privacy
• Expose chest fully

 

General Inspection

• Surroundings
  • Monitoring:
    • pulse oximeter
    • ECG monitoring
  •  Treatments:
    • Oxygen therapy (method of delivery, rate, sats, humidified, venturi)
    • Inhalers
    • Blue (reliever, short-acting B2 agonist e.g. salbutamol)
    • Brown (preventer, corticosteroids e.g. beclometasone)
    • Spiriva (tiotropium bromide, COPD patients)
    • Nebulisers (driven by air or oxygen?)
    • Non-invasive ventilation
    • IV infusions
    • Chest drains
    • Creon (capsules for CF patients with exocrine pancreatic insufficiency)
  •  Paraphernalia:
    • Food and drink or supplements
    • Sputum pots
    • Cigarettes/ nicotine patches/ gum

• Patient
  • Well or unwell?
  • Alert and orientated or drowsy and confused?
  • Comfortable at rest or in pain?
  • Body habitus?  Cachectic or obese?
  • Signs of respiratory distress:
    • Dyspnoea/ tachypnoea
    • Tripod posture
    • Use of accessory muscles
    • Pursed lip breathing
    • Flared nostrils, intercostal/ subcostal recession, tracheal tug (children)
  • Chest shape
  • Breathing pattern
  • Added breath sounds? Stridor, audible wheeze?
  • Colour? Pale and shocked or peripherally cyanosed?
  • Obvious scars
• Ask patient to cough – dry or productive

 

Oxford Medical Videos demonstration of a respiratory exam

 

Hands

• Inspect
  • Clubbing – perform Shamoroth’s window test and consider respiratory causes:
    • Abscess of lung
    • Bronchiectasis
    • Cancer of the lung (not SCLC)/ Cystic fibrosis
    • Empyema
    • Fibrosis
  • Cigarette tar staining (not nicotine!)
  • Peripheral cyanosis
  • Wasting of small muscles of hand
    • Especially dorsal interossei and thenar eminence
    • Can be caused by a C8/T1 lesion e.g. Pancoast’s tumour
  • Hand signs of rheumatological conditions or steroid use
• Palpate:
  • Pulse
  • RR
    • Normally 12-16 breaths per minute
    • Component of CURB-65
  • CO2 retention flap (also look for fine salbutamol-induced tremor)

 

Arms

• Signs of steroid use (thin skin, easy bruising)
• Cannulae
• Ask for BP (component of CURB-65)

 

Neck

• JVP – respiratory causes of ↑JVP:
  • Tension pneumothorax
  • Severe acute asthma
  • PE
• Carotid pulse (CO2 retention = bounding)
• Tracheal deviation
  • Normal = central
  • Deviated away = tension pneumothorax, large pleural effusion
  • Deviated towards = lung collapse, pneumonectomy

 

Face

• Facial swelling
• SVC obstruction (usually due to bronchogenic carcinoma)
• Smoker’s facies
• Horner’s syndrome
  • Unilateral miosis, ptosis and anhidrosis
  • May be caused by Pancoast’s tumour
• Conjunctival pallor (anaemia)
• Blue lips- peripheral cyanosis
• Mucous membranes (dehydration)
• Tongue (bright red = CO poisoning)
• Central cyanosis under tongue – respiratory causes:
  • Pneumothorax
  • PE
  • Pleural effusion
  • Pulmonary oedema
  • COPD
  • Acute severe asthma
  • Acute respiratory distress syndrome (ARDS)

 

Chest: anterior

• Examine anterior chest as quickly and efficiently as possible as most signs will be best detected on the posterior chest
  • Inspect (ask patient to put hands on hips)
    • Chest wall deformity
      • Pectus excavatam (‘funnel chest’ e.g. Marfan’s syndrome)
      • Pectus carinatum (‘pigeon chest’ e.g. severe childhood asthma)
      • Harrison’s sulcus (severe childhood asthma)
      • Barrel chest (asthma, COPD)
    • Breathing pattern
      • Seesaw breathing (diaphragm in, abdomen out on inspiration; severe airway obstruction)
      • Fail chest/ paradoxical breathing (fracture of 2 or more ribs anteriorly and posteriorly)
      • Kussmaul breathing (DKA)
      • Cheynes-Stokes/periodic breathing (comatose patient)
    • Missing ribs
    • Scars
      • Thoracotomy – pneumonectomy or lobectomy
      • Thoracoplasty – rib removal (commonly old TB)
      • Small scars in axillae (previous chest drains)
    • Radiotherapy tattoos
  • Palpate
    • Apex beat (may be impalpable in COPD, pleural effusion)
    • RV heave (cor pulmonale)
    • Expansion:
      • Lateral: symmetry, >5cm increase
      • AP: symmetry
  • Percuss
    • At apices and 3 places on each side, alternating sides in an S shape, then axillae
  • Auscultate
    • Same places as percussion
    • Vocal resonance
      • If an area of dullness is found, vocal resonance can be used to distinguish between consolidation (increased) and effusion (decreased).
      • It is not necessary to also perform pectoriloquy or tactile vocal fremitus, but it is important to be aware of them.

 

Chest: posterior

• It is often easier to detect pathology when examining the posterior chest so be thorough!
  • Inspect again
    • Scars
    • Radiotherapy tattoos
    • Deformity – particularly kyphosis or scoliosis
    • Breathing pattern
  • Palpate
    • Expansion- repeat lateral expansion
    • Lymph nodes
      • Cervical
      • Supraclavicular
    • Sacral oedema (cor pulmonale)
  • Percuss
    • Percuss the upper, middle and lower zones in an S shape
  • Auscultate
    • Same as percussion
    • Vocal resonance

Legs

• Peripheral oedema
  • Cor pulmonale
• Easy bruising
• Calf swelling (DVT)
• Erythema nodosum
  • Respiratory causes:
    • Viral/ streptococcal throat infections
    • Mycoplasma pneumoniae infections
    •  TB
    • Sarcoidosis

 

Closure

• Thank patient
• Patient comfortable?
• Help getting dressed?
• Wash hands
• Turn to examiner, hands behind back, holding stethoscope (try not to fidget!) before saying: “To complete my examination, I would like to…”
  • Bedside investigations:
    • Look at obs chart and repeat set of obs (pulse, BP, SATs, temp.)
    • Measure peak flow
    • Inspect any sputum pots and send for MCS
  • Further investigations as needed:
    • Bloods
    • Lung function tests
    • CXR

 

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Common Respiratory Examination exam questions for medical students, finals, OSCEs and MRCP PACES

 

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